Form SSA-7160-F4 Employment Relationship Questionnaire

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0040

TOE 420

EMPLOYMENT RELATIONSHIP QUESTIONNAIRE
This questionnaire is authorized by Section 205(a) of the Social Security Act, as amended (42 U.S.C. 405(a)). While you
are not required to respond, your cooperation will help us decide if the services performed by the worker can be credited
as employment for social security purposes. Your cooperation in completing and returning this form will be appreciated.
Please answer all items on this form; use "unknown" or "does not apply" if appropriate. If you need more space, use the
space for "remarks" on the last page or attach another sheet. For your convenience, we have enclosed an envelope
requiring no postage.

See Revised Privacy Act Statement Attached

FIRM'S NAME

WORKER'S NAME

ADDRESS OF FIRM

WORKER'S SOCIAL SECURITY NUMBER

FIRM'S FEDERAL EMPLOYER'S IDENTIFICATION

DATE WORKER'S SERVICES PERFORMED
FROM

TO

Note.- The term "worker" refers to the person who performed the services.
The term "firm" refers to the individual, corporation, partnership, association, or other type of organization for whom
the services were performed.
Check type of firm:
Partnership
Corporation
Other (specify)
Individual
1.

Give nature of firm's business (for example drugstore, home owner, radio manufacturer, farmer, etc.);

2.

State worker's occupation or title and give a complete description of the work done by him.

3.

(a) If the work was done under a written agreement or contract, please attach a copy.
(b) If the agreement was not in writing, describe the terms and conditions of the work arrangement.
(c) If the actual working arrangement differed in any way from the agreement explain the differences, why they
occurred and the date or dates of such change.

4.

(a) Was the worker given training in the work by the firm?
If "Yes," how often and what kind?

Yes

No

(b) Was the worker required to follow daily, weekly, etc., routines or schedules established
by the firm? If "Yes," explain the nature of the instructions

Yes

No

(c) Was the worker given instructions about the way the work was to be done?
If "Yes," explain the nature of the instructions

Yes

No

(d) Could the firm change the methods used by the worker in doing the work, or otherwise
direct him as to how to do the work?
Explain your answer

Yes

No

Form SSA-7160-F4 (12-1987) EF (7-2006)
Prior editions may be used until supply is exhausted.

5.

(a) Did the firm engage the worker:
Other (please explain)

Full-time

Part-time

Particular job

(b) Did the firm require the worker to work during fixed hours or at certain times?
If "Yes," explain.

Indefinite period

Yes

6.

Name the months and number of days worked in each month during this period of employment

7.

(a) State the kind and value of tools and equipment furnished by: the firm

No

the worker

(b) List any other expense connected with the work that the worker had:

8.

Was it agreed or understood that the worker would perform the services personally?
If "No," explain

9.

(a) Did the worker have helpers?
If "Yes," answer (b), (c) and (d).
(b) Were the helpers hired by:
If hired by the workers, was the firm's consent and approval necessary?
Who could discharge the helpers:

Yes

No

Yes

No

The worker?
Yes
The worker?

The firm?
No
The firm?

The worker?
Yes

The firm?
No

Hourly
Wage

Advance
or draw

(b) Was he guaranteed a minimum pay?

Yes

No

12.

Was the worker eligible for a pension, bonuses, paid vacations, sick pay, etc?
If "Yes," explain

Yes

No

13.

Did the firm carry workmen's compensation insurance on the worker?

Yes

No

14.

Were social security taxes deducted from amounts paid the workers?

Yes

No

Unknown

15.

How did the worker report his earnings for income tax purposes?

Wages

Self
employment
income

Unknown

16.

(a) Was the worker permitted to work for others if such work would not interfere with the services for the firm?
Yes
No
If "Yes," answer (b).

(c) Who paid the helpers:
If the worker paid the helpers, did the firm repay him?
(d) How much of the work did the helpers do?

10.

Who owned or rented the premises where the work was done?

11.

(a) Check the type of pay worker received:
Other (Please explain)

(b) describe any work he did for others:

Form SSA-7160-F4 (12-1987) EF (7-2006)

Salary

Commission

17.

(a) Could the firm discharge the worker at any time?

Yes

No

(b) Could the worker quit at any time?

Yes

No

(c) Would liability be incurred if the worker quit or was discharged before the job was completed?
If "Yes," explain
Yes

18.

No

(a) Did the worker work under:

His own
business name?

The firm's
name?

(b) Did the worker advertise or maintain a business listing in the telephone directory, a
trade journal, etc.?

Yes

No

(c) Did the worker hold himself out to the public as available to do work of this nature?

Yes

No

(d) Did the worker have a shop or office of his own?
If "Yes," where?

Yes

No

(e) Was a license or certificate needed for the work?
If "Yes," what kind?

Yes

No

Of any other nature?
If "Yes," explain

19.

Please explain in detail why you believe the worker was an employee of the firm or was an independent contractor.

20.

Has any other governmental agency ruled on the status of services performed by the worker
or another person performing the same or similar services?
Yes
If "Yes," attach a copy of the ruling.
ANSWER NO. 21 ONLY IF WORKER WAS AN AGENT-DRIVER OR COMMISSION-DRIVER
(a) List the products and/or services distributed (for example, bakery products, laundry services):

21.

No

(b) If the worker distributed more than one product or service, which was considered the principal or main product?
Explain

(c) Did the worker serve:
22.

Customers or routes designated by the firm?

ANSWER NOS. 22 AND 23 ONLY IF THE WORKER WAS A LIFE INSURANCE SALESMAN
Did the worker devote his/her entire or principal working time to the sale of life
or annuity contracts for the firm?

Form SSA-7160-F4 (12-1987) EF (7-2006)

The worker?

Both

Yes

No

23. (a) Under the terms of the original contact, was it agreed that the worker would work:
Other (please explain)

Full-time

Part-time

(b) Were these terms of the contract ever changed?
If "Yes," give the date and explain the changes

Yes

No

(c) Were the changes agreed upon by both the firm and the worker?

Yes

No

Worker

Firm

Yes

No

24. ANSWER NO. 24 ONLY IF THE WORKER WAS A HOME WORKER
(a) Who furnished materials or goods used by the worker?
Was the worker furnished a pattern of given instructions to follow in making
the product?
Explain

(b) Was the worker required to return the finished product either to the firm
Yes
or to someone designated by the firm?
25. ANSWER NOS. 25, 26, 27, AND 28 ONLY IF THE WORKER WAS A TRAVELING OR CITY SALESMAN
Did the worker have an exclusive territory?
Yes
Did the firm specify when and how often to work the territory?
Yes
If "Yes," explain

No
No
No

26. (a) What percent of his total sales for the firm were made to wholesalers, retailers,
contractors, or operators of hotels, restaurants, or other similar establishments?

27.
28.

%

What percent of his total working time was spent in making such sales?

%

(b) What percent of his working time for the firm was spent in selling to organizations other
than those specified in (a), such as manufacturers, schools, churches, homeowners, etc.?

%

What was the approximate number of hours worked per day for the firm?
Was the worker required to forward the orders to the firm?

Hours
Yes

No

REMARKS: (This space may be used for additional explanation)

I CERTIFY that all copies of contracts and all statements submitted herewith are true, correct, and complete to the best of
my knowledge and belief.
SIGNATURE

ADDRESS

Form SSA-7160-F4 (12-1987) EF (7-2006)

TITLE

DATE

See Revised PRA Statement Attached
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 25 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory
or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to
our time estimate to this address, not the completed form.

Form SSA-7160-F4 (12-1987) EF (7-2006)

SSA will insert the following revised PRA Statement into the form at its next scheduled
reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 25
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
meeting.

PRIVACY ACT STATEMENT
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information.
We will use this information to determine the worker’s potential eligibility for benefit payments
and if additional information is required.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the
worker’s claim.
We rarely use the information for any purpose other than for making a decision regarding
entitlements to benefits. However, we may use if for the administration and integrity of Social
Security programs. We may also disclose the information to another person or to another agency
in accordance with approved routine uses, which include, but are not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social
Security benefits and coverage;
2.

To comply with Federal laws requiring the release of information from our records
(e.g. to the Government Accountability Office and Department of Veterans’ Affairs);

3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigatory activities necessary to assure
the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally-funded and administered benefit programs and for repayment of
payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notice entitled, Claims Folders Systems, 60-0089. This notice, additional information

regarding our programs and systems are available on-line at www.socialsecurity.gov or at your
local Social Security office.